| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $81 | $81 | $81 |
| Left heart catheterization CPT 93458 • Cardiology | $244 | $244 | $244 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $179 | $179 | $179 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |
| Emergency department visit high severity CPT 99284 • Emergency | $93 | $93 | $93 |
| Emergency department visit highest severity CPT 99285 • Emergency | $303 | $303 | $303 |
| Auto-added CPT 10120 • General | $158 | $158 | $158 |
| Auto-added CPT 82565 • General | $5 | $5 | $5 |
| Auto-added CPT 92060 • General | $43 | $43 | $43 |
| Auto-added CPT 92504 • General | $25 | $25 | $25 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $536 | $536 | $536 |
| CT chest with contrast CPT 71260 • Imaging | $60 | $60 | $60 |
| CT angiography chest CPT 71275 • Imaging | $82 | $82 | $82 |
| X-ray ankle complete CPT 73610 • Imaging | $36 | $36 | $36 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $229 | $229 | $229 |
| Ultrasound transvaginal CPT 76830 • Imaging | $114 | $114 | $114 |
| Screening mammography bilateral CPT 77067 • Imaging | $123 | $123 | $123 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $2 | $2 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $8 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Hemoglobin A1c CPT 83036 • Laboratory | $6 | $6 | $6 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $41 | $41 | $41 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $158 | $158 | $158 |
| Psychotherapy 30 minutes CPT 90832 • Mental Health | $67 | $67 | $67 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $4 | $4 | $4 |
| Electroencephalogram (EEG) awake and asleep with activation CPT 95819 • Neurology | $449 | $449 | $449 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $58 | $58 | $58 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $98 | $98 | $98 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $217 | $217 | $217 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $232 | $232 | $232 |
| Office visit established patient minimal CPT 99211 • Office Visits | $17 | $17 | $17 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $38 | $38 | $38 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $109 | $109 | $109 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $166 | $166 | $166 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $121 | $121 | $121 |
| Initial hospital care high complexity CPT 99223 • Office Visits | $162 | $162 | $162 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $111 | $111 | $111 |
| Hospital discharge day management more than 30 min CPT 99239 • Office Visits | $110 | $110 | $110 |
| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $76 | $76 | $76 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $44 | $44 | $44 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $19 | $19 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $68 | $68 | $68 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $68 | $68 | $68 |